Fillable 278 - Andover Employment Application

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278 - Andover Employment Application

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BROWSE CITY OF ANDOVER (MN) FORMS

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Employment
Application
1685 CROSSTOWN BOULEVARD N.W. • ANDOVER, MINNESOTA 55304 • (763) 755-5100
FAX (763) 755-8923 •
MUST BE FILLED OUT COMPLETELY
Date
Name: __________________________________________________________________________________________________________________
Last First Middle
Home Phone: (
) - Work Phone: ( ) - ____________________________
area code area code
Current Address: ________________________________________________________________________________________________________
Street City State Zip
Prior Address: ___________________________________________________________________________________________________________
Street City State Zip
Email Address: ________________________________________________________________________________________________________
Applicant Note
This application form is intended for use in evaluating your suitability for employment. It is not an employment contract.
Employment with the City of Andover is at-will, during the probationary period, which means the employee has the right to terminate
their employment, with or without cause, at any time. Likewise, the City has the right to terminate an employee with or without cause,
during the probationary period. Please answer all appropriate questions completely and to the best of your ability. False or
misleading statements are grounds for refusal or termination of employment and benefits. The City of Andover is an equal
opportunity employer. All qualified applicants will receive consideration without discrimination on the basis of a person’s race, color,
creed, national origin, religion, age, sex, marital status, or physical handicap, except where a reasonable, bona fide occupational
qualification exists. Additional testing of job-related skills, mental/physical abilities, physical condition and for the presence of drugs
in your body may be required prior to employment.
Type of Work
For which position are you applying? _________________________________________ What date can you start? ______________________
Educational Data
SCHOOL PRINT NAME, NUMBER & STREET, CITY, STATE & ZIP CODE
& TELEPHONE NUMBER FOR EACH SCHOOL LISTING
DATE OF
GRADUATION
NUMBER OF
YEARS
COMPLETED
DEGREE, MAJOR
OR TYPE OF
COURSE
High School
College
Graduate School
Trade, Business, Night or
Correspondence
Other
WWW.ANDOVERMN.GOV
P:\New Hires\Andover Employment Application 2/24/2009
Employment History Please list most recent employment first
Name of Employer
Street Address City State Zip
Telephone Number (Include Area Code) Supervisor’s Name May we Contact?
o Yes o No
Your Job Title Employed Salary/Hourly Rate (optional)
FROM: (mo/yr) TO: (mo/yr) START: END:
Duties
Reason for Leaving
Name of Employer
Street Address City State Zip
Telephone Number (Include Area Code) Supervisor’s Name May we Contact?
o Yes o No
Your Job Title Employed Salary/Hourly Rate (optional)
FROM: (mo/yr) TO: (mo/yr) START: END:
Duties
Reason for Leaving
Name of Employer
Street Address City State Zip
Telephone Number (Include Area Code) Supervisor’s Name May we Contact?
o Yes o No
Your Job Title Employed Salary/Hourly Rate (optional)
FROM: (mo/yr) TO: (mo/yr) START: END:
Duties
Reason for Leaving
Name of Employer
Street Address City State Zip
Telephone Number (Include Area Code) Supervisor’s Name May we Contact?
o Yes o No
Your Job Title Employed Salary/Hourly Rate (optional)
FROM: (mo/yr) TO: (mo/yr) START: END:
Duties
Reason for Leaving
P:\New Hires\Andover Employment Application 2/24/2009
Skills
Indicate equipment you can operate: _______________________________________________________________________________________
Computer/Software Skills: _______________________________________________________________________________________________
Phone Systems: ________________________________Type:_________________________________Number of Lines: ____________________
Type: o Yes o No WPM:
Dictation: o Yes o No WPM:
Other Related Skills: _____________________________________________________________________________________________________
General Information
Are you legally authorized to work in the United States: o Yes o No
Do you have a valid Minnesota Driver’s License? o Yes o No
Have you previously applied for employment here? o Yes o No If yes, when? ________________________________________________
Have you previously been employed by this City? o Yes o No If yes, when? __________________________________________________
Military Service
Have you ever served in a U.S. military branch? o Yes o No Dates: __________________ Branch: _________________________________
Professional References Not Current Employers or Relatives–At Least Three
NAME AND ADDRESS OCCUPATION PHONE
Certification & Release
I certify that I have read and understand the “Applicant Note” on page one of this form and that the answers given by me to the
foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that
any false information, omissions or misrepresentation of the facts called for in this application may result in rejection of my application
or discharge at any time during my employment. I authorize the City and/or its agents, including consumer reporting bureaus, to
verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons,
schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said
person, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information.
I also understand that the use of illegal drugs is prohibited during employment. If City policy requires, I am willing to submit to drug
testing to detect the use of illegal drugs prior to and during employment.
________________________________________________________________________________________________________________________
Signed Date
P:\New Hires\Andover Employment Application 2/24/2009
Release of Information Authorization
As evidence of my desire to obtain employment with The City of Andover, I empower you and/or your agents to retrieve information
from all personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, any law
enforcement agency at the federal, state, or country level, worker’s compensation agencies or individuals, relating to my past activities,
to supply any and all information concerning my background, and release the same from any liability resulting in providing such
information. The information received may include, but is not limited to, academic, residential, achievement, job performance,
attendance, litigation, personal history, credit reports, driving history, disciplinary and conviction records.
I, the undersign, hereby authorize and grant my informed consent to permit the Bureau of Criminal Apprehension (hereafter “BCA”)
and the Anoka County Sheriff Office (hereafter “ACSO”) and/or its representatives all data classified as private which concerns me
and which may be in your possession. The data, classified as private under M.S. 13.02, Subd. 12, includes all data which has been
collected, created, received, retained or disseminated in whatever form which in any way related to my dealings with the BCA and/or
the ACSO. I understand that the purpose of permitting the CITY to have access to this information is to determine my suitability for
employment.
By signing this authorization, I hereby release the BCA and the ACSO from any and all liability which otherwise may or does accrue as
a result of the release of any and all data, regardless of its accuracy. I also release the CITY from any and all liability for its receipt and
use of data received pursuant to this consent. I understand that I am not legally required to sign this form, but if I do not, the CITY will
not be able to determine whether my conviction record is a job-related consideration.
I hereby certify that all the statements and answers set forth on the application form and/or my resume are true and complete to the
best of my knowledge, and I understand that if subsequent to employment any such statements and/or answers are found false or that
information has been omitted, such false statements or omissions will be just cause for the termination of my employment.
o No, I do not want a copy of any written background report regarding me.
o Yes, I would like a copy of any written background report regarding me.
Last Name First Name Middle Name
Previous Name Date Changed
Street Address
City State Zip Code
Social Security Number Date of Birth
Driver’s License Number State of License
I am willing that a photocopy of this authorization be accepted with the same authority as the original and this release expires one year
after the date of origination.
________________________________________________________________________________________________________________________
Signed Date
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278 - Andover Employment Application

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Completed 10 July 2020

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